Tennessee: A State of Epidemic
Tennessee ranks second per capita in the U.S. for prescription drug abuse. It’s a middle class epidemic. How did it happen in a state known for music and horses?
Editor's Note: This is the first in a Fix series looking at drug addiction issues in states and localities across the country.
Ask yourself what Tennessee is best known for and you will likely come up with Nashville and Graceland and then maybe mention Miley Cyrus, Dolly Parton, Davy Crockett - and horses galore. All happy stuff.
Then there is this: the state’s growing reputation as the home to a virtual epidemic of prescription drug abuse.
According to the Tennessee Medical Association, the Volunteer state (so named for the bravery of its troops in the War of 1812 and memorialized by the fact that a great many of its people sign up to go to war) ranks second per capita in the country for prescription drug abuse (first is West Virginia). It also has the eighth highest drug overdose mortality rate in the U.S. As Tommy Farmer, assistant special agent in charge of the Tennessee Bureau of Investigation, put it: “We’re in jeopardy of losing an entire generation of our youth to addiction if we don’t get a grip on this."
Then there's this disheartening information from David Reagan, chief medical officer of the Tennessee Department of Health: “We unfortunately have a national epidemic of babies being born dependent on legal or illegal drugs their mothers ingested during pregnancy. At birth, the baby is cut off from the drug and goes through a painful process of withdrawal. The condition is known as Neonatal Abstinence Syndrome or NAS, and it is painful for the baby and costly to society.”
“At the current rate this epidemic is progressing, we are projecting more than 800 drug-dependent newborns by the end of this year,” Dr. John Dreyzehner, the commissioner for the Tennessee Department of Health, said late last year. In 2011 there were 629, which startled much of Tennessee. Moreover, 35% of 142 pregnant women that were admitted to state-funded treatment services in Tennessee said prescription pain killers were their primary substance of abuse.
The number of prescription drug-related deaths in Tennessee is alarming. The overdose mortality rate in Tennessee is 16.9 deaths per 100,000 – in 1999 it was 6.1 per 100,000 - according to a 2013 report written by Trust for America's Health (TFAH) called “Prescription Drug Abuse: Strategies to Stop the Epidemic.” The national rate is 12.7. Around Tennessee you frequently hear this bit of state trivia: more people have died from accidental prescription drug overdoses than auto accidents in recent years.
Among the contributing factors is that Tennessee residents simply seem to need or trust meds more than most others - Tennessee currently ranks among the top three states for the number of prescriptions written per capita, with almost 18 a year for every person in the state. In this "I need my painkillers" and addictive climate, sales of two of the most popular prescription painkillers, oxycodone and hydrocodone, both addictive, soared. Oxycodone sales increased more than 500% from 2000 to 2010, while hydrocodone increased nearly 300%, both accounting for a significant portion of the epidemic.
Another driving force behind the epidemic was that before April 1, 2013, doctor and pharmacy reporting to most drug monitoring databases was voluntary, not mandatory. This was the perfect setup for easily obtaining - and cavalierly writing - scripts; perfect, in fact, for cheating.
Common belief is that addicts get their drugs from dealers or steal them. In reality, those who can do so get scripts. Those with less access to doctors, according to the Center for Disease Control, tend to obtain their drugs from friends or relatives; only an estimated 16% are bought from dealers.
In Tennessee, friends and relatives have an easy time becoming enablers because huge amounts pass through the state. A controlled substance database report presented to the Tennessee General Assembly in 2012 stated that in 2011, 275 million hydrocodone pills were dispensed in Tennessee, 117 million Xanax pills and 113 million oxycodone pills. That adds up to 22 Xanax pills, 51 hydrocodone pills and 21 oxycodone pills for every Tennessee resident over 12 years old.
As elsewhere, addictive prescription drugs in Tennessee do not discriminate by gender, race, or social standing - except in a reverse way. In Tennessee, people who are educated, married or successful with their careers are three times more likely to use prescription drugs than others and thus to find themselves addicted, according to the state Division of Alcohol and Drug Abuse Services.
“People don’t feel as if they are abusing drugs that were prescribed by a doctor,” explains Randy Jessee, senior vice president for Specialty Service at Frontier Health, the state’s largest chain of counseling and mental health centers. “It is also a part of a culture that says taking pills for an ailment is the right way to fix your problems."
Creating addiction-extending circumstance is the reality that more women become addicted than men, and then more men tend to seek treatment than women.
According to Jessee, the epidemic began in eastern Kentucky and spread to southwest Virginia before bleeding over to northern Tennessee. “It started in 1998 and by the year 2000, we had serious issues." Hyrocodone (the key ingredient in Lortab, Norco and Vicodin) and OxyContin, he notes, got a boost when they were marketed as non-addictive when first introduced during the 1990s. Then people started crushing the pills and snorting or injecting the drug, giving the user an instant and long-lasting high. In 2010, Tennessee’s per capita spending on prescription addictive drugs grew by 7.2 % to $1,272.94.
CORRUPT DOCTORS AND PILL MILLS
Addiction specialist Dr. Corely Slovis of Nashville cites two major reasons for the dramatic increases. For one, the trust and naivete of some patients. "To them, the drugs are clean. It's pure. It's from the doctor. It's from the pharmacist. It's from the corner store," Slovis said. Second, there were and are physicians hungry for money and who simply don't care if their clients become addicts. Because of this, doctor shopping in which a person visits multiple doctors to get the same (or similar) medications is fairly common in Tennessee. "There are caring and honest physicians and nurse practitioners who are trying to do good by someone in pain,” Slovis said. “But the other group of health care practitioners are helping to abuse the system for their own personal profit.”
To many people, these doctors are professional drug dealers. “My brother overdosed on pain pills two years ago,” said Jessica Johnson, a single mother and accountant. “Thank God he survived. But to me it was amazing that he was able to doctor shop so easily. He knew exactly where to go to get a fix and these doctors were happy to oblige. They would over-prescribe and give him his drug of choice. This kind of stuff happens all the time but is somehow ignored by the public.”
A former Memphis music producer who goes by the stage name “Casper” became addicted to Lortabs in 2010. “It actually helped my creativity in the (recording) studio,” he explained. “I don't know why but it made my creative juices flow a lot better. My imagination would take over. Weed and Lortab...that was my niche. When I was on it, I wrote and produced some of the best music I ever did. Rap, jazz, you name it. When I helped a young lady write a country song I knew this stuff was working good!”
According to Casper, doctor shopping was easy at the time. “I don't think the doctors knew what I was doing,” he said. “I would get something prescribed from one doctor and get it filled. Then I'd go to another doctor and get the prescription filled somewhere else. I kept doing it and when my addiction got worse, I would say the stuff wasn't working and they'd give me more pills.”
Casper says he decided to make a change after waking up one morning in a park with no recollection of how he got there. “I saw where the addiction was heading,” he explained. “I like to be in control of my life and the decisions I make. The Lortab addiction hurt my marriage for a while, too. I went to rehab and with the grace of The Lord and the support of my family I made it through.”
Alix Michel, a Chattanooga lawyer who has made the epidemic a personal cause célèbre and frequently gives public talks about it, notes that he often speaks to doctors and pharmacists who either are somehow not aware of the problem and write scripts heedlessly or are simply indifferent to the epidemic reality. "With the number of deaths now being more than automobile accidents, there should be a similar type of training program in place for prescription drugs," Michel says. "As a doctor, you have to carefully tailor your treatment to the patient standing in front of you. No one really is immune to this epidemic."
THE GOVERNMENT FINALLY STRIKES BACK
After the reported total of 1,062 overdoes deaths in 2011, the state government finally acted to confront the epidemic. In May 2012, Gov. Bill Haslam signed the Tennessee Prescription Safety Act that required all medical professionals to register with Tennessee's Controlled Substance Monitoring Database and check their patients' history of opiate or benzodiazepine drug use before prescribing pain medications. The law also mandated that dispensers and pharmacists update the database once a week instead of once a month.
The Act further cracked down heavily on doctor shopping by establishing information sharing across state lines. This limits abusers from using multiple doctors and pharmacies in more than one state . The database also allows clinicians to identify patients who have abused drugs or have the potential to abuse them. Once identified, these patients can receive counseling. “Clinician-patient conversations are especially important among women of childbearing age,” said Reagan.
Since April 1 of last year, nurse practitioners, physicians, dentists, oral surgeons, pharmacists and physicians' assistants have been required to use the database. Pharmacies began to participate just this past January.
"Less people will have access to drugs and more people will get treatment if we can stop it on the front end," explained Rodney Bragg, assistant commissioner for the Tennessee Department of Mental Health and Division of Alcohol and Drug Abuse Services.
“Just as we check for allergies before giving a medication intended to help a patient, medical professionals now check the database to help prevent these powerful medications from causing harm,” is how Dreyzehner put it. “We believe this requirement for clinicians to use the database will improve patient safety, provide opportunities for counseling and referral to treatment to prevent misuse and abuse of prescription drugs, and help to prevent the use of drugs for non-intended purposes.”
"There are many promising signs that we can turn this around - but it requires urgent action," said Jeffrey Levi, executive director of TFAH.
Numerous other ideas are being floated or are in the works, among them requiring individuals to show a picture ID when picking up someone else's prescription.
Doctors like Levi became more optimistic when Tennessee last year scored seven out of ten on a New Policy Report Card of promising strategies to help curb prescription drug abuse. In comparison with the other states in the calculations, Washington D.C. and 28 other states scored six or less, while Vermont and New Mexico scored the highest possible with a 10. South Dakota scored a two, the lowest of the participating states.
“I'm glad that they're working on things here in Tennessee,” said Johnson. “I'm glad that they're cracking down. My brother is doing better and I have a friend who is also in recovery. Tennessee was pretty embarrassing for a minute.”
“Dependence or addiction to prescription medicines is a serious behavioral health condition, but it is also treatable,” said E. Douglas Varney, another commissioner of the Tennessee Department of Mental Health and Substance Abuse Services.
There are several places available for drug-addicted Tennesseans to get help. Residents can call the Tennessee REDLINE at 1-800-889-9789, or go online to www.taadas.org/Redline.htm to learn about treatment and recovery services available in your area.